Abstract

BACKGROUND AND PURPOSE: The best management of upper ureteral calculi is undefined. We performed a prospective randomized comparison between semirigid ureteroscopy (URS) and shockwave lithotripsy (SWL) for upper ureteral stones <2 cm to evaluate safety and efficacy of both procedures.

PATIENTS AND METHODS: Patients with a single radiopaque upper ureteral stone <2 cm undergoing treatment between January 2010 and May 2011 in our department were included. Randomization was performed into two groups-group A: SWL performed as an outpatient procedure using an electromagnetic lithotripter (Dornier Compact Delta); group B: URS performed using an 6/7.5F semirigid ureteroscope with holmium laser intracorporeal lithotripsy. Statistical analysis was performed regarding demographic profile, success rates, retreatment rates, auxiliary procedures, and complications.

RESULTS: There were 90 patients enrolled in each group. Mean stone size: 12.3 mm in group A vs 12.5 mm in group B (P=0.52). The overall 3-month stone-free rate was (74/90) 82.2% for group A vs (78/90) 86.6% for group B (P=0.34). For stone size <10 mm, 3-month stone-free rates were (45/53) 84.9% for group A vs (43/49) 87.7% for group B (P=0.32). For 10 to 20 mm stones, 3-month stone-free rates were (29/37) 78.4% for group A vs (35/41) 85.4% for group B (P=0.12).The re-treatment rate was significantly greater in group A than group B (61.1% vs 1.1%, respectively; P<0.001). The auxiliary procedure rate was comparable in both groups (21.1% vs 17.7%; P=0.45). The complication rate was 6.6% in group A vs. 11.1% in group B (P=0.21).

CONCLUSIONS: Both SWL and semirigid URS are safe and highly efficacious for treating patients with proximal ureteral stones <20 mm. Forstones <10 mm, SWL was safer, less invasive, and of comparable efficacy with URS. For stones between 10 and 20 mm, however,n URS was more effective, with a lesser re-treatment rate.

Kommentare 1

This article is one of several prospective randomized comparisons between SWL and URS for removal of of 82.2% and 86.6% clearly demonstrate that both methods successfully can be used for treatment of ureteral stones. The well recognized fact that large stones might require repeated SWL sessions was confirmed. On the other hand it is important to remember that also with repeated sessions SWL remains a non-invasive method. It is difficult to elucidate how the rather mild analgesic routine affected the outcome.

One point that deserves a comment is the statement that SWL "...does not require surgical skills." Although SWL is not defined as a strictly surgical procedure, it nevertheless is necessary to have considerable experience and skill to circumvent various obstacles that otherwise contribute to inferior disintegration and need of repeated sessions. It is a common misconception that whereas the outcome of URS depends on the operator, that of SWL entirely depends on the lithotripter. This view, unfortunately, is wrong and without appropriate attention to basic principles of SWL there is a high risk that even technical improvements of SWL will have only small effects on SWL-success.

This article is one of several prospective randomized comparisons between SWL and URS for removal of of 82.2% and 86.6% clearly demonstrate that both methods successfully can be used for treatment of ureteral stones. The well recognized fact that large stones might require repeated SWL sessions was confirmed. On the other hand it is important to remember that also with repeated sessions SWL remains a non-invasive method. It is difficult to elucidate how the rather mild analgesic routine affected the outcome.
One point that deserves a comment is the statement that SWL "...does not require surgical skills." Although SWL is not defined as a strictly surgical procedure, it nevertheless is necessary to have considerable experience and skill to circumvent various obstacles that otherwise contribute to inferior disintegration and need of repeated sessions. It is a common misconception that whereas the outcome of URS depends on the operator, that of SWL entirely depends on the lithotripter. This view, unfortunately, is wrong and without appropriate attention to basic principles of SWL there is a high risk that even technical improvements of SWL will have only small effects on SWL-success.
Hans-Göran Tiselius